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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERNIIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # CAC-001173fi32 PROJECT CONTACT $ TELEPHONE # Dan Samuel 209-931-5513 <br /> F FACILITY NAMEMel Bokides Petroleum I PH°NE 209-943-2011 <br /> A <br /> d ADDRESS 2191 Navy Dr, Stockton ' Calif. <br /> I ' <br /> L CROSS STREET Tillie Lewis <br /> T OWNER/OPERATOR PHONE # <br /> Y Mel Bokides Petroleum 209-943-2011 <br /> C CONTRACTOR NAME Samuel Construction Co. PHONE 209-931-5513 <br /> 0 <br /> N CONTRACTOR ADDRESS p.0. BOX 737, VallE S rin S CA LIC # 383434 CLASS A, B, Haz <br /> T WORK.COMP.# , <br /> R INSURER State Compensation - <br /> AI <br /> C FIRE DISTRICTPERMIT # � <br /> After EED <br /> Cit of ck - -- 1 <br /> T <br /> 0 LABORATORY NAME <br /> R ~� COUNTY I PHONE # � <br /> M tlC ' <br /> SAMPLING FIRM Sam PHONE # <br /> TAN <br /> I1!lll111111111.111!1111111 <br /> TANK [D TANK SIZE+ I CHEMICALS STORED CURRENTLY/PREVIOUSLY GATE UST INSTALLED <br /> 39- /Z,0(� --G ?n nnn. T)i I aRn <br /> 39 .2�. <br /> A 39- <br /> u 39- ' <br /> K 39- 1 =.'— 20 , <br /> 39- I I I <br /> 39- 1 Q , onn <br /> I {1111!1!{11!11!111 11lllllil 11{{{111111{!1 1111!1 <br /> 1!11!1111 1{11!11 ll�llill 111 ill{!!llllbl��l�b1111}111111{1111!{{{{11 I <br /> P W <br /> L APPROVEDI 0.9 I APPROVED WITH CONDITIOlj' Ate 0iiISAPPROVED <br /> E CONDIT S BELOW AND/OR ON ATTACHMENT) <br /> < � - <br /> PLAN REVIEWER'S NAME � 1r -�� � DATE <br /> 1111i1i1lIII{I1lllillillllllllll11111111111111111111I11111111111III11111111U11lIllil111111111111illllliil11111111!{IIIlil111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNT`! ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATLOk LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE ORMANCE OF THE .WORK FOR WHICH T S PERMIT I5 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS "r <br /> APPLICANT'S SIGNA3OF ALIFORNLA. � / TITLE-C�?� 7.0 _ DATE r . <br /> CONDITION(S): JiL <br /> - S 7j �' a <br /> Cc�L�+a: .L, fv2Y � <br /> �+} C�{tiL�.�. Grl >>n J '✓`t- !� ..[-v�^-EU'�Z%.. � -..-Ct <br /> AL.i7i"y'- <br /> EH 23 046 (Revised 9/71/9 n P34'e 3 r <br />